Privacy is very important to us. No information sent to Intensive Therapeutics will in any way be distributed or shared without your acknowledgement and consent.
Instructions to complete registration forms:
- Complete the Contact/Medical Information form below and click the send button.
- Print out the following two forms:
a.Consent to Attend form 
b. Video Permission form
- Complete and sign these 2 forms and mail them to:
Intensive Therapeutics, Inc.
70 Darlington Drive
Wayne, NJ 07470
- Both forms must be completed, signed and the originals received at least one month before the start date of camp.
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Camp Leaps and Bounds Contact/Medical Info
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| Contact Information |
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Child’s Name:
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DOB:
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Parent’s Name(s):
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Address1:
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Address2:
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Home Phone Number:
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Cell Phone Number:
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Back-up Number:
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Email Address:
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| Medical Information |
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Is your child on any medications?:
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Yes No |
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Types of medications:
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Does your child have any allergies?
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Yes No |
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Please list allergies:
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Any other pertinent information?
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| Special Information and Family Goals |
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Is your child on a special diet?
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Yes No |
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If your child is on a special diet please give us some detials:
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What is your child’s main form of communication (verbalization, pictures, signs)?
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What are one or two realistic/functional goals you would like to see your son/daughter achieve during this camp?
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When your child is upset, does he/she have something (item, words, deep pressure) that helps him/her calm down?
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What are some of your child’s favorite toys, sayings, clothing, activities, etc?
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| Note: This message and any attachments are intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender by replying to this message and permanently deleting it from your system. |
